ID Design Press, Skopje, Republic of Macedonia
Open Access Macedonian Journal of Medical Sciences. 2018 Feb 15; 6(2):340-343.
https://doi.org/10.3889/oamjms.2018.085
eISSN: 1857-9655
Clinical Science
Prevalence of Depression Symptoms in Diabetes Mellitus
*
Salih Eker
Family Medicine, Adnan Menderes Street, Health Street 195, 54100 Adapazarı / Sakarya, Turkey
Citation: Eker S. Prevalence of Depression Symptoms in
Diabetes Mellitus. Open Access Maced J Med Sci. 2018
Feb 15; 6(2):340-343.
https://doi.org/10.3889/oamjms.2018.085
Keywords: Diabetes mellitus; Depression; Beck
Depression Index; A1c; Turkey
*Correspondence: Salih Eker. Şirinevler Family
Medicine, Adnan Menderes Street, Health Street 195,
54100 Adapazarı/Sakarya, Turkey. E-mail:
salihekerdr@hotmail.com
Received: 27-Nov-2017; Revised: 28-Dec-2017;
Accepted: 04-Jan-2018; Online first: 11-Feb-2018
Copyright: © 2018 Salih Eker. This is an open-access
article distributed under the terms of the Creative
Commons Attribution-NonCommercial 4.0 International
License (CC BY-NC 4.0)
Funding: This research did not receive any financial
support
Competing Interests: The authors have declared that no
competing interests exist
Introduction
Diabetes mellitus (DM) is one of the most
prevalent diseases all over the world and has
devastating complications for patients and economic
burden for nations [1]. Prevalence of DM in Turkey
has increased from 7.2% [2] to 13.7% [3] in 8 years.
Depression is also a condition with high
prevalence. All over the world, an estimated 300
million people of all ages suffer from depression [4].
Also, the World Health Organization (WHO; 2010)
declared that major depression carries the heaviest
burden of disability among mental and behavioural
disorders (3.7 % of all U.S. disability-adjusted life
years; and 8.3% of all U.S. years lived with disability)
[5].
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340
Abstract
BACKGROUND: Diabetes mellitus (DM) is one of the most prevalent diseases all over the world. Prevalence of
DM in Turkey is 13.7%. Depression is another condition which has a high prevalence. All over the world, an
estimated 300 million people of all ages suffer from depression. The relevance between depression and DM is a
well - known condition.
AIM: We aimed in this study to find out the prevalence of depression symptoms for DM in an attempt to better
manage the disease.
METHODS: We preferred the Beck Depression Index (BDI) to evaluate the depression symptoms.
RESULTS: The number of patients introduced the study were 171 (101 (59.1%) female). As a results of BDI 67
(39.2%) patients evaluated as normal [29 (28.7%) female], 54 (31.6%) had poor symptoms [35 (34.7%) female],
46 (26.9%) had moderate symptoms [34 (33.7%) female] and lastly only 4(2.3%) had strong symptoms 3 (3.0%)
female]. So 50 (29.2%) of patients had median plus strong symptoms. There were statistically significant
association between HbA1c stages and depression (P = 0.018).
CONCLUSION: Being a patient with DM is a strong indicator that the patient may have a depressive disorder. So
the physician who takes care patients with DM should be alert about depression, and the simplest way to
accomplish is BDI.
A study conducted in Istanbul determined that
40.1% of all participants have moderate to severe
depressive symptoms [6]. Furthermore, it is observed
to be prevalent in the city that the study is conducted.
The correlation between depression and DM
is a well - known condition which is investigated by
many researchers [7]. Prevalence of depression in
patients with DM may vary according to the type of
DM, gender and conditions they live in. While the DM
is a serious and important condition, depression must
be recognised to manage better and improve the
condition to prevent devastating outcomes well known
for DM.
This study aims to reveal the prevalence of
depressive symptoms among patients with diabetes in
our region. This way, we can rightly presume and
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diagnose depression in patients with DM and manage
it more precisely to improve outcome.
Methods
We selected patients randomly who came for
their routine Diabetes control as outpatients. After
evaluation of biochemical parameters along with
patient’s condition and informing the patient about the
test, the Beck Depression Index form was given to the
patient to fill out either at the clinic or to take home.
Data of 171 diabetic patients were collected,
recorded and evaluated on SPSS 20 statistical
program.
The study was conducted in a cross-sectional
manner to find out if a correlation exists between
depression symptoms and DM. Parameters used were
HbA1c values along with independent parameters like
age, gender and educational background. The study
was carried out in Sakarya Research and Training
Hospital in Turkey from December 2016 to January
2017. All the patients had diabetes. The exclusion
criteria for patients were a diagnosis of depression
and using any antidepressant drug.
The sample population consisted of 171
patients with diabetes. Within this population, 96 typed
2 using the oral antidiabetic drug (OAD), 61 were
using OAD plus insulin, 5 patients were using insulin
only, 2 were prediabetic, and 7 were type 1. We used
the Beck Depression Index (BDI) to evaluate
depression symptoms.
BDI was developed by Aron T. Beck. In BDI
there are 21 questions and 4 answers to choose, and
each question is graded from 0 - 3. The total points
are calculated and assigned ranging 0-9 is normal, 10
- 16 poor, 16 - 30 modest and over 30 is strong
[14][15].
Before using the BDI, the conducting
physician has been trained by psychologists. The BDI
questionnaire forms were given to patients at the time
of regular visit and had been collected for review. All
the forms were recorded together with other
parameters on SPSS 20 statistical program and then
evaluated. A p-value ≤ 0.05 was accepted as
statistically significant. Parameters such as gender,
age, marital status, and educational background, the
age of patient’s diabetes, diabetes therapy, HbA1c
and other biochemical parameters that were collected
in 3-month intervals were recorded. These were then
reviewed to determine the relationship between these
parameters and depression symptoms.
HbA1c is the strongest indicator for DM status
and is used to find out the control level of the disease
and to direct therapy [13]. HbA1c is analysed with the
TM
PremierHb9210 HbA1c analyser. We stratified
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Open Access Maced J Med Sci. 2018 Feb 15; 6(2):340-343.
Eker. Prevalence of Depression Symptoms in Diabetes Mellitus
HbA1c in five stages as 5.0 - 6.5, 6.5 - 7.0, 7.0 - 8.0,
8.0 - 9.5 and over 9.5 [12] and we calculate a mean
value of A1c for each patient collected in years to
determine the relevant stage of A1c.
The study protocol was approved by ethics
committee of Sakarya University. Approval was
obtained on July 31 of 2016 with the number of
71522473/050.01.04/18. Before giving the
questionnaire forms, all patients were informed about
the test, and their approvals were taken.
Results
There were 171 patients. The majority of
patients were female (n = 101; 59.1%).The mean age
was 59.11yrs with a min 30yrs, and a max 79yrs and
the majority of patients were under 65 years old
(77.2%). fifteen (8.8%) patients were illiterate, 100
(58.5%) elementary school, 18 (10.5%) middle school,
28 (17.0%) high school and 9 (5.3%) had college
degrees. The marital status of patients were 2 (1.2%)
single, 157 (91.8%) married, 2 (1.2%) divorced and 10
(5.8%) widowed. Most of the patients were
housewives (94; 55%), and the rest were retired
(26.9%), and 28 patients had other jobs, and only 3
were jobless. Smoking status of patients was 96
(56.1%) never smoked, 34 (19.9%) currently smoking
and 41 (24%) had smoked before. Alcohol status of
the patients was; 160 (93.6%) were alcohol naïve, 8
(4.7%) had rarely used, and 3 (1.8%) had previously
used. Mean duration of diabetes was 13.47 years
(ranging from newly diagnosed to 36 years). Data
were collected over a mean period of 7. 68 years.
DM treatment profile of patients were Oral
Antidiabetic Drug (OAD) 97 (56.7%), insulin 12 (7%)
and OAD + insulin 62 (36.3%). Most of the patients
had concurrent diseases especially hypertension [118
(69%)] and dyslipidemia [141 (82.5 %)]. Further 16
(9.4%) patients had ischemic heart disease (IHD), and
16 (9.4%) hypothyroid, and also 1 had allergic
asthma, 1 colitis, 1 hepatitis carrier, 1 chronic
obstructive pulmonary disease, 1 ischemic heart
disease + asthma bronchial, 1 larynx carcinoma (CA),
1 has had tuberculosis, 1 premature menopause, 1
prostate CA, 2 rheumatoid arthritis and 1 ulcerative
colitis.
As mentioned before we tried a new method
of staging HbA1c (We stratified HbA1c in five stages
as 5.0 - 6.5, 6.5 - 7.0, 7.0 - 8.0, 8.0 - 9.5 and over 9.5)
to reveal the association between HbA1c and
depression. The relevance is depicted in the table.
Also as shown in Figure 1, there was a statistically
significant association between HbA1c stages and
depression p = 0.018.
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Table 2: Correlation between depression symptoms and DM

type, HT and dyslipidemia
Poor Med Strong
Normal P
Symptoms Symptoms Symptoms
1(1.5%)C↓ 0(0.0%) 1(2.2%) 2(1.2%)
Prediabetes n=2 (1.16%)
(50%)R→ (0.00%) (50%) (0.00%)
1(1.5%) 2(3.7%) 4(8.7%) 0(0.0%)
Type 1 Diabetes n=7 (4.09%)
(14.2%) (28.57%) (57.1%) (0.00%)
Type 2 DM n=96 39(58.2%) 33(61.1%) 22(47.8%) 2(50.0%)
0.879
(OAD) (56.14%) (40.62%) (34.37%) (22.91%) (2.08%)
Type 2 DM 2(3.0%) 2(3.7%) 1(2.2%) 0(0.00%)
n=5 (2.92%)
(Insulin) (40.00%) (40%) (20%) (0.00%)
Tip 2 DM n=61 24(35.8%) 17(31.5%) 18(39.1%) 2(50.0%)
OAD&Insulin (35.67%) (39.34%) (27.86%) (29.50%) (3.27%)
Yes n=118 49
34 (28.8%) 32 (27.1%) 3 (2.5%)
(69.00%) (41.5%)
Hypertension 0.675
No n=53
18 (34%) 20 (37.7%) 14 (26.4%) 1 (1.9%)
(30.99%)
Yes n=141 54
45 (31.9%) 39 (27.7%) 3 (2.1%)
(82.45%) (38.3%)
Dyslipidemia 0.916
No n=30 13
9 (30%) 7 (23.3%) 1 (3.3%)
(17.54%) (43.3%)

Figure 1: Relation between depression and mean A1c stage

Although high school (13.8%) and college
(11.1%) degree patients had less moderate
As a results of Beck Depression Index 67 depression symptoms, it should be kept in mind that
(39.2%) patients appreciated as normal [29 (28.7%) most of the patients (n = 100) had elementary school
female and 38 (54.3%) male], 54 (31.6%) had poor degree. P = 0.59 (Table 1).
symptoms [35 (34.7%) female and 19 (27.1%) male],
46 (26.9%) had moderate symptoms [34 (33.7%) The association between dyslipidemia and
female and 12%) male] and lastly only 4 (2.3%) had hypertension is detailed in Table 2 respectively.
strong symptoms [3 (3.0%) female and 1 (1.4%)
male]. Therefore, 50 (29.2%) of patients had shown
median plus strong symptom (Table 1).
Discussion
Table 1: Correlation between depression symptoms and
gender, education, DM age and HbA1c levels

Normal
Poor
Symptoms
Med
Symptoms
Strong
Symptoms
P This study investigated depression symptoms
Subjects Total N=171 67(39.18%) 54(31.57%) 46(26.90%) 4(2.33%) and its association with some parameters in patients
Female n=101
(59.06%)
29(28.7%) 35(34.7%) 34(33.66%) 3(2.97%) with DM. This study revealed that 29.2 % of patients
Gender 0.007
Male n=70
38(54.3%) 19(27.1%) 12(17.1%) 1(1.4%) with DM have depression symptoms. It should be kept
(40.93%)
No Education in mind that BDI results given here are not diagnostic
4(26.7%) 6(40.0%) 4(26.7%) 1(6.7%)
n=15 (8.77%)
Pre n=100
but rather to give direction for further referral to a
40(40%) 25(25%) 32(32%) 3(3.0%)
(58.47%) specialist. Most of the patients who have depression
Med n=18
Education
(10.52%)
6(33.3%) 7(38.9%) 5(27.8%) 0(0.0%) 0.459 symptoms were female. Some studies found a high
High n=29
14(48.3%) 11(37.9%) 4(13.8%) 0(0.0%) prevalence between depression and DM [8] and the
(16.95%)
University n=9 results of our study complied with these results.
3(33.3%) 5(55.6%) 1(11.1%) 0(0.0%)
(5.26%)
0-5 Years n=16
7(43.75%) 6(37.5%) 3(18.75%) 0(0%) DM patients with depression are more prone
(9.4%)
6-10 Years n=47
21(44.68%) 14(29.78%) 11(23.40%) 1(2.12%)
to poor glycemic control in general. This vulnerability
DM Age (27,4%) 0.863
11 Years And
is yet to be explicitly understood. It is thought that
Over n=108 39(33.33%) 40(34.18%) 35(29.91%) 3(2.56%) depression is caused by changes of the
(63.2%)
%5,0-6,5 n=36 neurotransmitters in the brain. These are dopamine,
16(44.4%) 11(30.6%) 9(25.0%) 0(0.0%)
(21.05%) serotonin and norepinephrine. These affect mood and
%6.5-7.0 n=39
15(38.5%) 14(35.9%) 8(20.5%) 2(5.1%) behaviour. Counterregulatory hormones such as
(22.80%)
HbA1c %7.0-8.0 n=40
Levels (23.39%)
21(52.5%) 13(32.5%) 6(15.0%) 0(0.0%) 0.018 catecholamines, glucocorticoids, glucagon and growth
%8,0-9.5 n=34
12(35.3%) 8(23.5%) 13(38.2%) 1(2.9%) hormones are secreted during psychological stress
(19.88%)
%9,5> n=22 [9]. Activation of counter-regulatory hormones
3(13.6%) 8(36.4%) 10(45.5%) 1(4.5%)
(12.86%) counteract the insulin action and can worsen glucose
excursion. Increasing glucose levels may complicate
While the relationship between DM type and the control of diabetes. And poor glycemic control
depression symptoms was not statistically significant especially in DM with complications could worsen
in a general mean (P = 0.892) statistically significant depression symptoms and could lessen the response
differences between patients with type 2 OAD (25% to antidepressant therapy [10]. While the relationship
moderate plus strong symptoms) and patients with between depression and DM is well known, only 31%
type 2 OAD plus Insulin (32.8 % moderate plus strong of patients with DM and depression use
symptoms) was noted (Table 2). antidepressant therapy [11].
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In our study based on BDI, we found that
29.2% of patients with DM had depression symptoms
with prevalence higher in females (36.7% moderate
plus strong symptoms) when compared to males
(18.5% moderate plus strong symptoms), p = 0.001.
In conclusion, the prevalence of depression
symptoms in patients with diabetes in a region where
Turkish people live was somewhat higher than
reported for other countries. Being a diabetic
especially a female and having a poor managed DM
were strong indicators that the patient may have
depressive disorder. Hence the physician who takes
care of patients with DM should be alert to the
possibility of depression and the simplest way to
accomplish this is the Beck Depression Index.
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